Expert: Marc Rubin, RPh Asthma Educator - 8/25/2008

Question
Hi,

I am currently on Advair which works fine.  However I’ve read that Advair can be unsafe and that one with mild asthma should consider Flovent instead.  Any thoughts?

Below is an excerpt taken from:

http://health.msn.com/health-topics/articlepage.aspx?cp-documentid=100205363

Advair

It's asthma medicine... that could make your asthma deadly. Advair contains the long-acting beta-agonist (LABA) salmeterol. A 2006 analysis of 19 trials, published in the Annals of Internal Medicine, found that regular use of LABAs can increase the severity of an asthma attack. Because salmeterol is more widely prescribed than other LABAs, the danger is greater — the researchers estimate that salmeterol may contribute to as many as 5,000 asthma-related deaths in the United States each year. In 2006, similarly disturbing findings from an earlier salmeterol study prompted the FDA to tag Advair with a "black box" warning — the agency's highest caution level.

Your New Strategy

No matter what you may have heard, a LABA, such as the one in Advair, is not the only option, says Philip Rodgers, Pharm.D., a clinical associate professor at the University of North Carolina school of pharmacy. For instance, if you have mild asthma, an inhaled corticosteroid such as Flovent is often all you need. Still wheezing? "Patients can also consider an inhaled corticosteroid paired with a leukotriene modifier," says Dr. Rodgers. This combo won't create dangerous inflammation, and according to a Scottish review, it's as effective as a corticosteroid-and-LABA combo.

Kind Regards,

Mike


Answer
Hi Mike,

I really appreciate that you sent the article along with your question. Personally, I viewed the article was a case of irresponsible journalism.
 At no point in the entire piece did the author advise the reader that they should not make any changes in their therapy without talking to their health care provider. Furthermore, many "facts" presented were erroneous, and taken out of context. For example:the 5000 deaths per year being related to LABA's, ahhem...there are ~ 5000 deaths per year in the US due to asthma, and number that hasn't really changed in the past few years despite identifying a growing number of asthmatics. In fact, there is no correlation between the severity of the illness and the risk of death. If anything, the deaths are mostly attributable to the patient not carrying their rescue medication with them, and having a fatal trigger induced asthma attack.
 LABA's are NOT a first step treatment in persistent asthma, inhalation steroids, such as Flovent, Asthmanex or Pulmocort, are the first step. Adding a LABA shows greater benefit than adding a leukotriene, should step up therapy be necessary, although the other primary option is increasing the inhalation steroid dose. It really is patient dependent.

Proper therapy is guided by 1) controlling triggers, and 2) adjusting therapy to keep your inflammation under control. It is a dynamic process that may vary seasonally. For instance, if after 3 months of Advair therapy, your use of rescue medication has been twice a week or less during the day, and twice a month or less during sleeping hours, your physician may want to have you just on the Flovent. If after doing this change, you remain under the same control, great. But one needs to take seasonal variations into account, and only do this if the next three months you do not project seeing an increase in triggers, such as, ragweed is kicking up now and there will be more weed pollens in the next few months. If this is what you are sensitive to, then it is NOT the time to reduce your therapy. So you see that like in the old saying, look to the past to see what may lie before you.

The "black box warning" came from the results of a study called the "Smart Study" which upon follow-up analysis, had significant flaws in the design, where patients were given the two components of Advair, but as separate inhalers. The patients began to realize that just the LABA gave them relief, and stopped the steroid. This was fully against  the published guidelines. This resulted in loss of control of the inflammation, something that LABA's were not designed to do. This study soon became known as the "Not So SMART Study". There are more details to this, but this should suffice.

Bottom line, you are doing what every good patient should be doing...asking questions! Learn all you can to master the illness, and you should not become part of that "5000".

I belong to the American Academy of Allergy, Asthma and Immunology, and if you go to the patient education section, it is constantly updated with new information for you to use.

http://www.aaaai.org/patients.stm

I'll be interested in seeing if I get a response from the Professor at Duke. :)

To your health!!

Sincerely,

Marc